Behold the Referral! "Just go to the ER"

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One of my patients today... because I love sharing stories:

One dude came in with right lower leg redness and swelling after backing into a few tree branches a couple days prior. Urgent care correctly diagnosed cellulitis but sent him to the ER to “rule out septic joint.” On exam the erythema was localized to the calf... no involvement of the knee or ankle, and the patient was moving his knee and ankle just fine. Are you kidding me right now?
 
ERCAT said:
One of my patients today... because I love sharing stories:

One dude came in with right lower leg redness and swelling after backing into a few tree branches a couple days prior. Urgent care correctly diagnosed cellulitis but sent him to the ER to “rule out septic joint.” On exam the erythema was localized to the calf... no involvement of the knee or ankle, and the patient was moving his knee and ankle just fine. Are you kidding me right now?
Click to expand...
In a similar fashion...

Lady who got scratched while outside by piece of wood on her deck 3 days ago. Has mild cellulitis around it, no abscess. Sent from urgent care for, word-for-word on her discharge papers, a “spreading blood infection.” Of course she was terrified.
 
I find the very well appearing "my doctor says I have a life threatening blood infection" patients frequently leave unsatisfied when I don't poison them with broad spectrum antibiotics and admit them to the hospital.
WildcatS11 said:
In a similar fashion...

Lady who got scratched while outside by piece of wood on her deck 3 days ago. Has mild cellulitis around it, no abscess. Sent from urgent care for, word-for-word on her discharge papers, a “spreading blood infection.” Of course she was terrified.
Click to expand...
 
ERCAT said:
One of my patients today... because I love sharing stories:

One dude came in with right lower leg redness and swelling after backing into a few tree branches a couple days prior. Urgent care correctly diagnosed cellulitis but sent him to the ER to “rule out septic joint.” On exam the erythema was localized to the calf... no involvement of the knee or ankle, and the patient was moving his knee and ankle just fine. Are you kidding me right now?
Click to expand...

WildcatS11 said:
In a similar fashion...

Lady who got scratched while outside by piece of wood on her deck 3 days ago. Has mild cellulitis around it, no abscess. Sent from urgent care for, word-for-word on her discharge papers, a “spreading blood infection.” Of course she was terrified.
Click to expand...

I think the real reason these people are sent to the ER is those UC doctors or midlevels aren't sure if they just have a local infection or sicker. I just wish they would be truthful and say "could you get some labs and see if this patient needs something more than PO abx, I'm not really sure." And just admit that you want a second opinion.

Just about all routine non-septic cellulitis does just fine with PO antibiotics and raising the affected part (with few exceptions). I don't think size of cellulitis makes much difference. If people follow directions, they will do OK.
 
GeneralVeers said:
Every time. Patients expect it. Far easier to give antibiotics than deal with complaints later.
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I’m FM but I never give antibiotics after an I&D. I’ve never had anyone complain. Every once in awhile someone will ask if they need them and when I explain why they’re fine with it. In my experience it’s nothing like the begging for antibiotics for an URI.

Is that why I see people coming from the ED or UC with antibiotics after an I&D, to reduce complaints?
 
In my experience, patients want something done. The I&D checks the block for something done, so I never had much of a pushback when I didn't prescribe antibiotics.
 
AMEHigh said:
I’m FM but I never give antibiotics after an I&D. I’ve never had anyone complain. Every once in awhile someone will ask if they need them and when I explain why they’re fine with it. In my experience it’s nothing like the begging for antibiotics for an URI.

Is that why I see people coming from the ED or UC with antibiotics after an I&D, to reduce complaints?
Click to expand...

You may be one of the good ones, but I can't count the number of times I have had complaints because someone's PMD has thrown me under the bus: "What?? That stupid ER doctor didn't give you antibiotics?"

Also if they come back worse, with spreading cellulitis it's easier to defend my care. A URI? Don't give a crap, it's going away regardless so I don't give ABX ever (but I see tons of PMDs give out a Z-pack).
 
I almost always give them.


Conclusion:
The use of systemic antibiotics for skin and soft tissue abscesses after incision and drainage resulted in an increased rate of clinical cure. Providers should consider the use of antibiotics while balancing the risk of adverse events.
 
I do 90 percent of the time. If the abscess is very small and there’s ZERO surrounding cellulitic change, I am very comfortable just sticking with the I and D. But otherwise, if there is even a shred of doubt, they’re going home with Keflex and Bactrim... I judge myself internally every time I write the prescriptions... sometimes I even tell them to wait till the next day to take the Rx to see if it’s much better and I am sure it usually is.
 
The literature has gone back and forth on whether antibiotics improve outcomes. Most recently it says yes. But if it's an abscess and you're giving antibiotics, you only need Bactrim.
ERCAT said:
I do 90 percent of the time. If the abscess is very small and there’s ZERO surrounding cellulitic change, I am very comfortable just sticking with the I and D. But otherwise, if there is even a shred of doubt, they’re going home with Keflex and Bactrim... I judge myself internally every time I write the prescriptions... sometimes I even tell them to wait till the next day to take the Rx to see if it’s much better and I am sure it usually is.
Click to expand...
 
TooMuchResearch said:
The literature has gone back and forth on whether antibiotics improve outcomes. Most recently it says yes. But if it's an abscess and you're giving antibiotics, you only need Bactrim.
Click to expand...
Unless bactrim has poor sensitivity in your area. Or they have cellulitis, of which bactrim doesn't cover the non MRSA strep strains well.
 
RustedFox said:
How many people still give abx for an I&D'ed abscess?

Show of hands, now.
Click to expand...

if there is cellulitis around then abscess I do
sometimes it's purulent cellulitis and I do an I&D just to promote or enhance some drainage, then I do
sometimes I do because it's easy

if they are homeless or their body is filthy with dirt and grime I do
if they are diabetic I usually do

sometimes I don't
all depends.
sometimes it depends on what mood I'm in
sometimes I'm in a fighting mood and I fight with patients all the time who want useless medical care
sometimes I'm *not* in a fighting mood and I order useless CT's, blood tests, abx, and other things so I can just leave the damn pt room sane
 
Treatment of uncomplicated cellulitis should be monotherapy - if it's purulent you do "X" if it's non-purulent you do "Y". X and Y are single drugs.
If you I&D an abscess and you should treat for purulent cellulitis. It's monotherapy. Just follow the flowsheets / algorithms by IDSA, which are basically copied into AAFP, UTD, and just about every other place you find them.

Very rarely...when I'm not sure if something is purulent or not even with looking with ultrasound, I'll give Abx to cover both purulent and non-purulent. Probably happens <10% of the time.

It is quite uncommon to have multiple strains causing cellulitis (like strep, staph, etc.)
 
Yeah, yeah, yeah - I concede defeat on this one. When I typed "abscess", I just thought "poke the pus pocket and punt it home". Simple and well-circumscribed ones without other factors? Steel and byeee. You guys correctly took me to the woodshed on things like "surrounding cellulitis, cormorbidities, etc, etc."
 
RustedFox said:
Yeah, yeah, yeah - I concede defeat on this one. When I typed "abscess", I just thought "poke the pus pocket and punt it home". Simple and well-circumscribed ones without other factors? Steel and byeee. You guys correctly took me to the woodshed on things like "surrounding cellulitis, cormorbidities, etc, etc."
Click to expand...

But not for "patient experience"?
 
GeneralVeers said:
But not for "patient experience"?
Click to expand...

I like you a lot, Veers - but I do not order the c-spine films (or do a lot of other things the patients "want" just because they "want" them). If your abscess will do just fine without abx, then I'm not giving them.
 
RustedFox said:
I like you a lot, Veers - but I do not order the c-spine films (or do a lot of other things the patients "want" just because they "want" them). If your abscess will do just fine without abx, then I'm not giving them.
Click to expand...

I guess it depends on the patient population. If it's going to result in me losing my job from too many complaints I'm going to do it.
RustedFox said:
I like you a lot, Veers - but I do not order the c-spine films (or do a lot of other things the patients "want" just because they "want" them). If your abscess will do just fine without abx, then I'm not giving them.
Click to expand...

I've been defeated by the system. I fully agree with you. Unfortunately I don't want to lose my job paying $300+ as it would be hard to get another one these days. That being said, I don't give narcs to anyone, and don't order needless head CTs or give out antibiotics to URIs.
 
GeneralVeers said:
I guess it depends on the patient population. If it's going to result in me losing my job from too many complaints I'm going to do it.
Click to expand...

I get you, man. I work in the "country club" ER . Nevermind that, I'm going to involve them in a discussion about x-rays versus CTs, and document the whole thing in "shared decision making" language. Autotexts make it easy. If you're just a country-club mom and family (who all come to the ER in five-somes for their x-rays so their attorney can [whatever] ) then they need to get the message that they need to knock it off. If they want to irradiate their 12 year old, I refuse, and document the hell out of it.
[/QUOTE]

If you're afraid of getting fired by the system with that level of good documentation, then I'd reconsider where you're working, and why you're doing what you're doing.

Yes, before you ask: I'll "risk" my 300 dollar an hour job on patient satisfaction. I'd rather break the system.

Sorry, homeboy. I still love you.
 
"Go to the ER" is an incantation used specifically by clinic based physicians to ward off the demon Malpratice Lawyer. They said it, their staff says it, they even record it on their answering machines.
 
Groove said:
What's more...inevitably, we have this one hospice company that has no contract with the hospital for in patient hospice (they have a contract with the hospital down the street) and they will always bring them to us.
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Can't your ED director +/- your hospital brass have a discussion with your EMS director and get this fixed? I'm guessing they don't just put them in an uber and send them over...? Or does the hospital brass want them coming to you to collect extra $ despite not being the facility that holds the contract?
 
Old_Mil said:
Can't your ED director +/- your hospital brass have a discussion with your EMS director and get this fixed? I'm guessing they don't just put them in an uber and send them over...? Or does the hospital brass want them coming to you to collect extra $ despite not being the facility that holds the contract?
Click to expand...

One would think... Though, I think they have fixed the issue with the uncontracted hospice company as I haven't seen one of them in awhile. Fingers crossed.
 
GeneralVeers said:
I guess it depends on the patient population. If it's going to result in me losing my job from too many complaints I'm going to do it.


I've been defeated by the system. I fully agree with you. Unfortunately I don't want to lose my job paying $300+ as it would be hard to get another one these days. That being said, I don't give narcs to anyone, and don't order needless head CTs or give out antibiotics to URIs.
Click to expand...
Same. I hold firm on narcotics, xanax, and stuff with kids (they don't get antibiotics for URIs). Otherwise, whatever the patient wants so long as its not completely ridiculous/unsafe.
 
VA Hopeful Dr said:
Same. I hold firm on narcotics, xanax, and stuff with kids (they don't get antibiotics for URIs). Otherwise, whatever the patient wants so long as its not completely ridiculous/unsafe.
Click to expand...

Exactly my algorithm. Ankle X-ray for your sprain from 3 weeks ago? Sure. Acutely lower your asymptomatic BP of 160/93? No chance in hell.
 
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